Adrenal Flashcards
what are 2 conditions w/ hyperfunction of the adrenal gland
Cushing’s syndrome
Hyperaldosteronism
what are conditions that lead to Hypofunction of the adrenal gland
Primary adrenal insufficiency- Addison’s Disease
Secondary adrenal insufficiency
what Stimulates the release of adrenocorticotropic hormone (ACTH) from the anterior pituitary
Hypothalamus releases corticotropin-releasing horming (CRH
ACTH stimulates the adrenal gland to release
cortisol
Also releases aldosterone and androgens
in response to ↓ blood pressure, salt depletion, CNS excitation what is released from the kidney
renin
what condition leads to ↑adrenal function =↑cortisol production
cushing’s syndrome
what are ACTH-dependent cushing’s syndrome
Pituitary tumor: excess ACTH secretion
Stimulates adrenal glands to secrete excess cortisol
Ectopic disease: ACTH secretion from another tumor
What are ACTH independent cushing’s syndromes
Adrenal adenoma: benign
Adrenal carcinoma
Exogenous Steroids
S/S of cushing’s
central obesity purple striae along lower abdomen moon face supraclavicular fat pads buffalo hump (fat in the dorsocervical area) HTN glucose intolerance muscle weakness osteoporosis gonadal dysfunction (amenorrhea)
how to confirm cushing’s disease?
Elevated urinary free cortisol- confirms hypercortisolism
to determine the cause of cushing’s what should you get?
plasma ACTH
what is the treatment of choice for tumor w/ cushing’s
surgery
what is used for non-surgical canidates w/ cushing’s due to a tumor
Steroidogenic Inhibitors
what are Steroidogenic Inhibitors
metyrapone
Aminoglutethimide
what will initially occur w/ metyrapone
increase in plasma ACTH are first then will stop
ADRs of metyrapone
alopecia
hirsuitism
HTN
N/V
inhibits conversion of cholesterol to pregnenolone in adrenal glands
Blocks conversion of androstenedione to estrone and estradiol in the peripheral tissues
used for ectopic ACTH
Aminoglutethimide (Cytadren®)
ADRs of Aminoglutethimide (Cytadren®)
N/V
sedation
hypothyroidism (blocks synthesis of thyroxine)
antifungal agent that also inhibits synthesis of androstenidone. used for adrenal adenoma
keotconazole
adrs w/ ketoconazole
Hepatotoxicity
Monitor LFTs
Gynecomastia – decreased testosterone levels
Nausea
absorption of ketoconazole required what?
an acidic pH
what are adrenolytic agents
mitotane
cytotoxic drug that results in atrophy of the adrenal cells, also used for adrenal carcinoma
mitotane
what must you monitor w/ mitotane
urinary free cortisol
ADRs w/ mitotane
N/V – administer with food
Lethargy and somnolence
Hypercholesterolemia
with primary aldosteronism where is the problem
adrenal cortex due to aldoesterone producing adenoma of hyperlasia
results from stimulation of the zona glomerulosa by an extraadrenal factor (usually RAAS) but also due to excessive K+, pregnancy, CHF, cirrhosis, renal artery stenosis
secondary aldosteronism
how to differentiated primary and secondary aldosteronism
plasma-renin activity ratio
S/S of hyperaldosteronism
Hypertension Hypervolemia Hypokalemia Hypernatremia Leads to fluid retention Muscle weakness Fatigue Headache
if hyperaldosteronism isn’t due to a tumor of surgery isn’t an option what is the DOC?
spironolactone (aldosterone antagonist)
what to minotr w/ spirolonlactone
Blood pressure
Sodium and potassium
SCr
ADRs w/ wpironolactone
Hyperkalemia
Gynecomastia
an alternative aldoestonate antagonist for thsoe that can’t tolerate spironolactone ?
epleronone
what is due to destruction of the adrenal cortex. causes a deficiency in cortisol, aldosterone and androgens
primary addison’s
what causes secondary adrenal insufficiency?
suppression of HPA axis from exogenous steroid use
what is an ACTH deficiency
Deficiency in cortisol and androgens
Not mineralcorticoids
S/S and adrenal insufficiency
weakness/ fatigue anorexia N/V abdominal pain HPOTN craving of salt hyperpigmentation muscle/joint symptoms sexual dysfunction
labs findings w/ addison’s
Hyponatremia
Hyperkalemia
Hypercalcemia
Azotemia
diagnosis of adrenal insufficnecy
cosyntropin stimulation (synthestic ACTH) if adrenal glands are functionign normally plasma cortisol levels should rise (rules out primary adrenal insufficiency cause)
tx for addison’s disease
glucocorticoid replacement
most of it given up in morning
what is dosing compared back to w/ glucocorticoids
back to prednisone
what do you need to monitor w/ glucocorticoids
monitor symptoms every 6-8 weeks look for glucocorticoid excess or lack of improvement and adjust dose appropriately
what is a mineralcorticoid replacement? (only for primary)
fludrocortisone
S/S of mineralcorticoid insufficiency
Hypotension
Hyponatremia
Hyperkalemia
signs of excess mineralcorticoids
Hypertension
Edema
Hypokalemia
what can cause secondary adrenal insufficiency
high dose glucocortidois for long term
after tx is stopped adrenals can’t generate enough cortisol
what are S/S of glucocorticoid withdrawal
Malaise, myalgias, weakness, fatigue, anorexia
what is an important risk factor for secondary adrenal insufficiency?
time- longer duration of therapy w/ glucocorticoids there is more risk
ADRs of chronci glucocortidois
weight gain, increased appetitie
modd changes euphoria to depression
psychosis
opthalmology problem w/ chronic glucocorticoids
cataracts when gluccocorticoids are used later in life
glaucoma (increase intraocular pressure)
CV problems with chronic glucocorticoids
HTN
Dyslipidemia (increased TC, LDL, TG)
Heme effects with chronic glucocorticoid use
Immunosuppression
Infection
Impaired wound healing
GI ADRs w/ glucocorticoids
PUD (may occur more w/ NSAID use)
suppression of response to H. Pylori
If a person is on glucocorticoids for >3 months what should you screen for?
osteoporosis- DEXA scan
do preventative bisphosphonate therapy plus calcium and vit d
aseptic necrosis hip, growth supression, myopathy
Endocrine ADRS w/ glucocoritcoids
Cushing’s syndrome
adrenal suppression
glucose intolerance/ exacerbation of DM
Visible ADRs w/ chronic glucocorticoids
Skin-Acne
Easy bruising- loss of collage support for BV
thin skin- atrophy
striae- atrophy of the SubQ tissue
If a steroid is taken for longer than 1 week what should be done?
tapered down
Education to give to patients on glucocorticoids
take with food never stop abruptly wear a medial ID Ensure daily calcium intake is adequate ADRs
what can cause acute adrenal insufficiency (adrenal crisis)
trauma, surgery, illness, stress
what are signs and symptoms of acute adrenal insufficiency?
shock coma N/V weakness lethargy
what do patients w/ adrenal insufficiency need?
stress doses of glucocorticoids
IV fluids, BP support
what can be used to decrease potassium levels?
Fludrocortisone (mineracorticoid)
what is an injectable glucocorticoid that a patient can use in an adrenal crisis?
Injectable hydrocotisone or dexamethasone
what is released from the anterior pituitary
GH (somatropin) prolactin ACTH TSH LH FSH
what hormones come from the posterior pituitary?
Oxytocin
Vasopresin (ADH)
what is the excessive production of GH typically due to a GH secreting pituitary adenoma?
acromegaly
how do you diagnose acromegaly
oral glucose tolerance test then do a
GH level >1mcg/L
elevated IGF-1 levels
Tx for acromegaly
Surgery to remove the adenoma
what are 3 pharm treatments for acromegaly
somatostatin analogs
dopamine agonists (decrease GH production)
GH receptor antagonist
what is a somatostatin analgos? this is first line med therapy for acromegaly
Octreotide
ADRs w/ Octeotide
N/D Hyperglycemia Arrhythmias Hypothyroidism Cholelithias
what are 2 dopmaine agonist?
bromocriptine
ergot alkaloid
how long does it take for dopamien agonists to have a clinical response (have an immediate labl effect)
4-8 weeks
ADRs w/ dopamine agonists
N/V
HA, dizziness
HPOTN
what is a GH receptor antagonist. FDA approved for second tine therapy for acromegaly. Response seen in 2 weeks
Pegvisomat
what must you monitor w/ Pegvisomat?
AST and ALT levels
what is the most common presentation of GH deficiency?
short stature (>2 SD below population average)
what is an acquired disorder that is similar to GH deficiency?
GH insufficiency
First line tx for children for GH deficiency
recombinant GH
other indications for GH
turner's prader-willi children w/ chronic renal insufficiency idiopathic short stature adult GH deficiency (injury to pituitary) short-bowel syndrome AIDS wasting syndrome
what do all GH products contain? how are they given
somatropin
all given IM or SC
how long does GH therapy continue for?
until growth velocity decreases to <2.5 /year after puberty
ADRs w/ recombinant GH
Slipped capital femoral epiphysis
Idiopathic intracranial hypertension
what is a recombinant insulin-like growth factor-1 (IGF_1) approved for children s/ short stature due to primary IGF-1 deficiency
mescasermin
ADRS w/ mescasermin
hypoglycemia
dizziness
arthralgias
what inhibits PRH signal?
dopamine
Persistent prolactin levels > 20 mcg/L
Affects women of reproductive age
hyperprolactinemia
10x the normal prolactin levels inhibit what?
gonadotropic secretion and sex-steroid synthesis
will go into a menopause state
increased risk for osteoporosis
what can cause drugs induced hyperprolactinemia
DA Antagonists
prolactin stimulators
verapamil
what are DA antagonists
Antipsychotics
Phenothiazines
Metoclopramide
what are prolactin stimulators
Methyldopa Reserpine SSRIs Estrogens/Progestins Protease inhibitors Benzodiazepines TCAs MAO-I H2-receptor antagonists Opioids
S/S of hyperprolactinemia in women
Anovulation Oligomenorrhea or ameorrhea Infertility Galactorrhea Decreased libido Hirsutism Acne
S/S of hyperprolactinemia in male patients
Erectile dysfunction Infertility Decreased muscle mass Galactorrhea Gynecomastia
Tx for hyperprolactinemia
bromocriptine- stimulates dopamine receptors
cabergoline- long acting dopaming agonist
Tx of infertility due to hyperprolactinemia
Use barrier contraceptive method until prolactin levels are normalized
Reduce dose to minimum therapeutic dose before attempting to become pregnant
what is the first line of tx for prolactinomas
cabergoline (better efficacy than bromocriptine)
ADRs of cabergoline
valvular heart dz when used in high doses for long term
monitoring for hyperprolactinemia
serum prolactin q3-4 weeks after drug initiation
once serum levels normalized monitor every 6-12 months
